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General NPI Number Information
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NPI Number | 1073981247
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Entity Type | Organization
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Legal Business Name | PLAY MOVE GROW PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 09/04/2015
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Last Update Date | 09/04/2015
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Provider Practice Location Address
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Address Line | 2539 NORMA ST
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City | TITUSVILLE
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State | FL
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Zip | 32780-2845
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Country | US
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Telephone | 321-446-0064
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Fax |
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Provider Business Mailing Address
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Address Line | 2539 NORMA ST
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City | TITUSVILLE
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State | FL
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Zip | 32780-2845
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Country | US
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Telephone | 321-446-0064
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JEANETTE K VAN DUYNE
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Credential |
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Telephone | 321-446-0064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | PT 18971
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License Number State | FL
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